Evaluating the role of Kasai portoenterostomy in biliary atresia older than 90 days.

Purpose: Biliary atresia (BA) patients presenting after 90 days of age face contentious treatment decisions between Kasai portoenterostomy and direct liver transplantation. This study evaluated outcomes of Kasai portoenterostomy in older BA patients to inform therapeutic decision-making.

Methods: A retrospective multicenter study analyzed 32 BA patients who underwent Kasai portoenterostomy beyond 90 days of age. Primary outcomes included jaundice clearance (total bilirubin < 20 μmol/L) and two-year native liver survival. Patients were stratified by jaundice clearance status for comparative analysis.

Results: The median surgical age was 110 days (IQR: 98-119 days). Twenty patients (62.5%) achieved jaundice clearance, while 12 (37.5%) failed to clear jaundice. All patients achieving jaundice clearance survived with their native Liver at two years, with only one requiring transplantation in the fourth postoperative year. Conversely, none of the non-clearance patients achieved two-year native Liver survival, with 11 undergoing transplantation for progressive cholestasis at a median of 5 months postoperatively and one death after declined transplantation. Surgical age was the most significant predictor of success, with ROC analysis yielding an optimal cutoff of 109 days (AUC: 0.779), while histological fibrosis stage also showed significant association with outcomes".

Conclusion: Kasai portoenterostomy remains clinically meaningful in selected older BA patients, with 109 days representing a critical surgical threshold. This approach is particularly valuable in resource-limited settings where liver transplantation availability is constrained.